5. RESULTADOS DEL ANÁLISIS
5.2. Corpus β (2011)
5.2.1. La grafía guion
Currently, four payment systems and one special arrangement contribute to the financing of home nursing at the federal level:
1. A mixed system of fee-for-service payment and lump sum payment: the nomenclature of nursing interventions and activities;
2. Specific costs for home nursing organisations (since 2002);
3. Subsidy for the costs related to computerization;
4. Reduced social tax contributions (Social Maribel) and Social Agreements between the federal government, organisations of employers and organisations of employees.
2.5.3.1 The Nomenclature of Nursing Interventions and Activities
Two types of nursing interventions and care provisions have to be distinguished: a fee-for-service system for technical nursing interventions and a lump sum system for nursing interventions for patients suffering from dependency/deficiencies in the activities of daily living (ADL)20.
The nomenclature of home nursing summarizes a limited list of nursing care activities/interventions which are reimbursed by NIHDI (appendix 3).
The rules and tariffs for financing home nursing are endorsed by the agreement committee. In the agreement committee, representatives of home nurses on the one hand and representatives of health insurance organisations on the other hand negotiate which nursing interventions are financed and they determine the tariffs of the interventions. The Medical Evaluation and Inspection Department of the NIHDI is responsible to control care delivery.
ADL-measurement
The distinction between fee-for-service financing and lump sum financing are based on the scores on the Belgian Evaluation Scale for Activities of Daily Living (BESADL).
BESADL is an adaptation of the ‘Index of ADL’21. The tool evaluates the six original domains of the ‘Index of ADL’: bathing (personal hygiene), dressing, transfer, toileting, continence, and eating (feeding). Each function is scored 1 (no help) to 4 (complete help), a higher score indicating higher dependency. Inter-rater accuracy of the dependency evaluations is under continuous supervision of the medical and nurse advisors of NIHDI and health insurance agencies.
A patient is considered as dependent for a function if the score for that function is higher than 2. Using a Boolean logic algorithm a global score is classified in one of four hierarchical dependency levels: baseline level (no dependency or low dependency level);
level A (dependency for bathing, dressing and transfer or toileting); level B (dependency for bathing, dressing, transfer, toileting and continence or eating); level C (the highest score for at least five functions, except continence or eating, which may have a score 3) (Table 5).
Table 5 : Criteria for determining levels of nursing care at home using the Belgian Evaluation Scale (BESADL)
BES scores
Financing type No ADL dependency 111111 Fee-for-service financing
Minimal dependency for washing 211111 Fee-for-service financing, 2 hygienic care sessions allowed per week (on weekdays) Minimal dependency for washing and
dressing and nocturnal urinary incontinence while continence during the day
221121 Fee-for-service financing, daily hygienic care allowed
Minimal dependency for washing and dressing and moderate to severe dementia (medical certificate)
221111 Fee-for-service financing, daily hygienic care allowed
Total dependency for washing and dressing 441111 Fee-for-service financing, daily hygienic care allowed
Dependency for washing, dressing, and
transfer or toileting 333111 or
331311 Level A (palliative) lump sum payment Dependency for washing, dressing, transfer,
continence and toileting or eating 333323 or
333332 Level B (palliative) lump sum payment The score equals 4 for washing, dressing,
transfer, continence and toileting or eating 444443 or
444434 Level C (palliative) lump sum payment The scoring is embedded in a list of hierarchical mapping criteria, which makes that theoretical combinations are in some cases mapped in a higher level (for details see Arnaert (1999)22.
Home care patients reimbursed under at least level A dependency require daily hygienic care. A minimal dependency respectively identified by BESADL-scores or a doctor’s attestation confirming moderate to severe dementia, determines the subject’s eligibility for daily hygienic nursing care.
Financing and BESADL
Globally, 64 billing codes can be classified in various categories (see appendix 2). The same billing codes apply for employed or self-employed home nurses.
• Low dependent patients are reimbursed through fee-for-service related payments. With exception of hygienic nursing care, a doctor's prescription is required for reimbursement of all nursing interventions in the fee-for-service payment system.
• Patients who score highest on care dependency (BESADL measurements) are reimbursed through per diem lump sums. The lump sum system is a type of fee-for-service payment system based on the number of days of care20. For patients with at least level A dependency, all nursing interventions are reimbursed by a lump sum per day, which covers all nursing care delivery on one day. Payments are calculated on the need for nursing care during 24 hours per day. A doctor's prescription is not required for reimbursement of nursing care delivery under the lump sum system, except for technical interventions under fee-for-service such as injections, wound care, bladder care, gastro-intestinal care, specific technical nursing interventions, …).
• Additional per diem lump sums apply to palliative care and diabetic patients.
Over half of the overall amount (407 million euro) is reimbursed for per diem care in patients for whom the degree of dependency is established by means of the BESADL scale. In 2003, 18 511 healthcare professionals delivered reimbursed homecare with an average reimbursed amount of 34 483€ per professional.
Pseudo codes are established in order to document the nursing interventions in patients under the lump sum payment system. These pseudo codes have to be transmitted along with the nomenclature codes of the lump sum payments.
Patients with a palliative medical certificate receive higher reimbursement on top of general reimbursement rules for home nursing.
Calculating the tariff
The tariff/honorarium for each nursing intervention is calculated by multiplying a generic value of the key-letter W with a specific coefficient for that nursing intervention: e.g. for hygienic care on weekdays at the patients’ home, the coefficient equals 1.167 (see Appendix 2). The honorarium equals € 4.82 and it was calculated by multiplying
€ 4.13113 (value of W on January 1st, 2009) with 1.167 (coefficient of hygienic care on weekdays). The value of the key-letter W depends on the Belgian health index which is used for adapting the nurse’s wages.
For the years 1995-2005, the evolution of W-value was lower (+17%) than the evolution of the health index (+18%), which means that the evolution of tariffs was lower than the evolution of the nurse’s wages. As a consequence, organisations employing home nurses were confronted with higher personnel cost increases than the incremental fees-for-service. Since 2006, the evolution of the W-value equals the evolution of the health index.
The value of the coefficient is determined by the NIHDI agreement committee and is specific for each activity delivered at a particular moment (week-weekend) and location (at home, group homes for handicapped persons, …). Using different values of the coefficient, different tariffs were established for care provision on weekdays and during the weekend or official holidays.
Honoraria were determined for a limited set of nursing interventions delivered in the nurse’s practice room or in a temporary or final group homes for handicapped persons.
The honorarium/fee for a single nursing intervention may change by adjusting the coefficient. For example, in 2007, the tariffs for intravenous injections were re-evaluated by adjusting the coefficient from 0.484 to 0.532 (+10%).
Limitation and ceilings
In order to limit supply-induced care provision in the fee-for-service financing, a maximum day-limit was fixed based on the amount of level A lump sum payment.
With regard to costs of materials, there is no general rule. It is assumed that an implicit consensus exists (in the agreement committee and in NIHDI) that the honorarium/fee for common technical nursing interventions includes the costs of small disposable materials needed for administering these nursing interventions (G. Lombaerts, NIHDI, 2009; personal communication). With regard to more expensive materials for specific technical nursing interventions (e.g. the tube for connecting an intravenous perfusion), a NIHDI-guideline on the nursing intervention ‘Installation of a permanent catheter or material/needle for medication administration in an implantable medication infusion device’, which specifies that the required materials are comprised in the honorarium.
The required average numbers of visits per day in patients in the lump sum financing system are:
• Level A lump sum financing: 1.15 visits per day on average
• Level B lump sum financing: 1.40 visits per day on average
• Level C lump sum financing: a minimum of 2 visits per day
Linking reimbursement to qualifications
In the past, reimbursement and tariffs were generally not linked to the qualification level of the nurse: all nurses were authorized to perform most of the nursing interventions of the nomenclature. Recently there is a growing trend to allow reimbursement of some nursing interventions only if they are performed by nurses with higher professional qualifications. For example, self-management education of a diabetic patient is only reimbursed if performed by a specialist nurse in diabetes.
Since 1997, payment for specific technical nursing interventions was limited to acts performed by diploma and bachelor nurses. In 2006, a list of nursing interventions which may be delegated from nurses to care assistants was published. Reimbursement of nursing interventions by care assistants was introduced under experimental conditions in 2007.
Reimbursement of nursing interventions for patients with a specific medical disease/condition.
The presence of a specific medical diagnosis is a condition for the administration of specific nursing interventions:
1. payment of daily hygienic care for patients with moderate to severe dementia, documented by a doctor’s certificate.
2. payment of preparation and administration of medication in patients with schizophrenia or bipolar mood disorder. For these chronic psychiatric patients, the prescribing medical doctor must document these medical conditions in the patient’s medical files.
3. nursing interventions in patients with type 2 diabetes on doctor’s prescription: education and follow-up. The number of diabetes educations administered by home nurses have gradually increased from 132 patients in 2003 to 856 patients in 2007 (Source: NIHDI reports). The follow-up aims to enhance self-management of diabetic patients. In 2002, diabetic patients received on average more than one visit of a home nurse per day23.
4. palliative care. Since 2001, expenditures for palliative patients in home care gradually increase (Table 6).
Table 6 : Evolution of the expenditures in home nursing care in palliative patients
Year Expenditures in palliative nursing care at home
Evolution since the year before
Percentage of total expenditures in home nursing
2001 531 446.61 € / 0.09%
2002 16 755 329.48 € / 2.76%
2003 25 482 177.28 € + 52.1% 3.94%
2004 33 808 746.28 € + 33.7% 4.83%
2005 38 646 023.78 € + 14.3% 5.30%
2006 43 546 760.74 € + 12.7% 5.57%
2007 49 977 027.60 € + 14.8% 5.94%
Source: NIHDI reports ‘Palliative care’
Rules for avoiding cumulative reimbursements
Rules were established to avoid double payments from a combination of nursing care delivery at home with care delivery in another setting. Double payments from the budget of home nursing and the budgets of homes for the aged, skilled nursing facilities, day centres, day hospitals, psychiatric nursing homes are prohibited. Neither is it allowed to combine specific nursing interventions of the nomenclature. For example, combination of the nursing interventions with regard to simple wound care (nomenclature codes 424336, 424491, 424631, 424793) or complex wound care (codes 424351, 424513, 424653, 424815) with the visit and advice of a specialist nurse in a patient with specific wound care (424395, 424690, 424852) is not allowed.
Co- payments for the patient
While for most outpatient health care, patients are in principle required to pay up-front the full fee and then claim reimbursement with their sickness fund3, regulations for nursing care delivery at home allow the third-party payer system. Patients only pay user charges.
Generally, the level co-payments of the patient for home nursing is (approximately) 25%
of the tariff. For some nursing interventions patients do not have to contribute, e.g. the lump sum payments for specific nursing interventions in diabetic patients, or payments for nursing interventions in palliative patients.
In order to promote accessibility of nursing care, the personal contribution of the patient is not collected by many home nursing providers. Moreover, in recent years the NIHDI took some decisions to reduce the level of co-payment.
• in 2007, the personal contribution was reduced from 25% to 20% for the levels B and C lump sum payment of nursing care.
• in 2008, the personal contribution for the levels B and C lump sum payment was again reduced from 20% to 15% (Program Law of 21.12.2007, registered on 31.12.2007).
Control
There are currently two control procedures in home nursing:
1. Inspectors of the Medical Evaluation and Inspection Department of the NIHDI check the proper use of the Belgian Evaluation Scale and check whether past reimbursements of nursing care match the actual care delivery.
Although it is a basic task of the NIHDI Medical Evaluation and Inspection Department to control nursing care delivery, currently there are no reports available on control mechanisms on some of the general principles in the nursing payment system, e.g. :
a. minimal activity requirements in the lump sum payment system. In some NIHDI reports, average numbers of visits per day are shown for the global care delivery in the Belgian population.
b. under-registration of pseudo-codes is a well-known problem2. For patients with lump sum payments, invoices should mention pseudo-codes for the first to the fifth visit and for the nursing interventions. A lack of administrative control on billing data can potentially explain this problem.
2. Medical advisors of the sickness funds united in the National College of Medical Advisors, in cooperation with the Health Care Department of the NIHDI, perform checks of the proper use of the Belgian Evaluation Scale. For both procedures, a visit and consultation of the patient at home is required.
They recently developed a new procedure for control of the proper use of the assessment instrument. Since January 2009, the Health Care Department of the NIHDI monthly selects a fixed number of home nurses for control in a random sample per province. These selected nurses receive a letter confirming that their patients might be visited by the medical advisors within a few weeks and that in between, the nurses may change/adapt the evaluation scores attributed to the patients. A second random sample of home nurses is selected from the first sample and medical advisors actually carry out control of the care dependency levels of all patients with lump sum financing in this second sample. If the National College of Medical Advisors detects systematic abuse of the assessment instrument by a home nurse, then the nurse’s file is referred to the Health Care Department of the NIHDI for further investigation, eventually for a legal prosecution. Medical advisors of sickness funds are responsible for control. At each time of a control 10% of the overall prevalent patient population under lump sum payments is randomly selected to be controlled by medical advisers of the sickness funds. There is no control of patients receiving hygienic care delivery in the fee for service
system, which is a huge and growing number. There are no criteria for defining systematic abuse of the assessment instrument, and it is not clear which sanctions are to be foreseen and which defence or lawful counsel a nurse may apply or which are the procedures for appeal.
2.5.3.2 Specific costs for home nursing organisations
Since 2002, specific costs for home nursing organisations are financed (Royal Decree of 16 April 2002, modified by the Royal Decree of 7 June 2004). Specific costs were defined as costs for organisation, coordination, programming, continuity, quality and evaluation. The objective of this subsidy was to promote collaboration of home nurses.
In order to receive a subsidy for specific costs, the following criteria have to be met:
• The organisation is under authority and supervision of a nurse who is responsible for planning, coordination, programming, continuity, quality and evaluation.
• The organisation is employing a minimum of 7 full-time-equivalent nurses, not including the supervising nurse.
• The organisation is exclusively employing employee-nurses; there are no self-employed nurses.
• The organisation implements permanent education for at least 20 hours per year per full-time-equivalent nurse.
• The organisation guarantees consultation and peer review for at least 25 hours per year per full-time-equivalent nurse.
• The organisation uses one unique third party payer’s number.
Originally, only organisations working with employee-nurses could receive this subsidy.
Since 1 September 2004, associations of self-employed nurses can receive a subsidy too.
The subsidy is paid every three months and amounts 11 151 euro for 14 full-time-equivalent nurses, not including the supervising nurse. Services applying for this subsidy have to document the number of nurses employed by the service and the activities of the service during the preceding trimesters. The yearly expenditures for these costs significantly increase from one year to another (Table 7).
Table 7: Yearly expenditures for specific costs of organisations for home nursing
Year Expenditures Evolution since the year before 2003 11 820 752 euro
2004 12 775 478 euro +8.08%
2005 13 517 473 euro +5.81%
2006 14 424 044 euro +6.71%
2007 15 369 389 euro +6.55%
Source NIHDI: OW 2008/54, November 2008
2.5.3.3 Subsidy for costs relative to the use of a computer software
Since 2006, a yearly financing of € 350 per nurse was introduced for costs relative to the use of a certified computer software. From 2008, the subsidy is € 800 per nurse.
The introduction of the VINCA standard, which is an experiment in 2008-2009 will allow easier control of care provision in the future , because for every visit by a home nurse, the patient’s identity will be checked electronically using the SIS-card or the E-ID card.
2.5.3.4 Job creation in home nursing by reduced social tax contributions and social agreements (2000 and 2005)
Although reduced tax contributions as a measure of financing home nursing do not belong to the core scope of the present study, these measures represent an important and structural part of the financing mechanisms in home nursing. Since 1997, a tax reduction (Social Maribel) was introduced of a fixed amount per trimester for each employee with at least 49% FTE employment. Part of the employer’s social tax contribution is refunded to create additional employment of employee-nurses and to reduce job strain in not-for-profit healthcare and welfare organisations of employee-nurses (Table 8).
Table 8: Overview of the effect of Social Maribel measures: social tax reductions and job creation
Year Payments to the
social fund Measure Social tax reduction
Number of created
employments in half-time-equivalents
1997 Maribel 1 80.57 euro 113
1998 2 949 524.47 Maribel 2 161.13 euro 159
1999 5 310 870.88 Maribel 3 241.70 euro 180
2000 7 067 903.00 Maribel 4 288.18 euro 28
2001 7 745 888.02
2002 7 739 068.00
2003 9 915 771.10 Maribel 4+ 288.18 euro 136
2004 10 598 669.64 Maribel 5 332.00 euro 80
2005 12 060 404.15 Maribel 6 354.92 euro 61
2006 12 060 404.15
2007 12 164 627.00 5
2008 12 164 627.00 1
2009 12 164 627.00
Total 111 942 384.41 763
Source: personal communication, Social Funds Maribel
2.5.3.5 Specific arrangement for nursing assistance in haemodialysis and peritoneal dialysis at the patient’s home
Since 2001, the Agreement Committee for hospitals adopted lump sum funding for haemodialysis and peritoneal dialysis at the patient’s home. The arrangement consisted of a lump sum payment to the hospital, which might or might not include a payment for nursing assistance at home (Table 9). If a home nurse carries out the nursing assistance at the patient’s home, she has to make an agreement with the hospital in order to receive the payment from the hospital.
Table 9: Lump sum payments to hospitals for financing dialysis at home Type of dialysis Payment for
dialysis at home Haemodialysis € 289.55 per
haemodialysis
It was stated in the Agreement Committee for home nursing (NIHDI) that payments for nursing assistance in dialysis at home were too low19. In 2006, this specific payment system for dialysis at the patient’s home was used for 1 938 patients (32.5%; both with and without nursing assistance) of a total of 6 504 dialysis patients in Belgium24.